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The Fontan procedure enables survival in individuals with univentricular physiology but is associated with progressive circulatory failure. Identifying predictors of adverse outcomes is essential to improve long-term management. This study evaluated five-year outcomes and baseline predictors of major events in a previously characterised paediatric and young adult Fontan cohort.
Methods:
This retrospective longitudinal study included 51 patients (median age 18 years, interquartile range 11) who underwent comprehensive evaluation between 2018 and 2019, including echocardiography with atrial strain analysis and cardiopulmonary exercise testing. The composite outcome comprised death, heart transplantation listing, hospitalisation for heart failure, or conduit thrombosis. Univariable and multivariable logistic regression identified predictors of adverse outcomes.
Results:
During a five-year follow-up, 7 patients (14%) met the composite outcome. Those with events had lower body mass index (19.8 kg/m2 [4.1] vs 16.9 [3.6]; p = 0.007), lower atrial conduit strain (10.95% [8.95] vs 2.8 [6.2]; p = 0.011), reduced peak oxygen uptake, and higher VE/VCO2 slope. In multivariable analysis, lower body mass index (OR 0.49, 95% CI 0.26–0.93; p = 0.028) and reduced atrial conduit strain (OR 0.70, 95% CI 0.51–0.96; p = 0.026) were independently associated with adverse outcome, with excellent model discrimination (AUC = 0.95).
Discussion:
Both nutritional status and atrial functional parameters demonstrated a strong association with the outcome. Reduced atrial conduit strain, reflecting diastolic dysfunction, and lower body mass index, possibly reflecting myopenia or cachexia, identified higher-risk patients and potential areas for intervention. Routine assessment of atrial function and nutritional status should be integrated into clinical surveillance and risk stratification of the Fontan population.
The relevation model is a fundamental tool in reliability engineering for assessing the effectiveness of redundancy allocation in coherent systems. In this study, we address the problem of allocation of relevations for one or two nodes in a coherent system with independent components to enhance system reliability. We establish results concerning the usual stochastic and hazard rate orders for coherent systems. Moreover, we illustrate our findings with a range of examples and counterexamples. In addition, we conduct a simulation-based study and a real data analysis to further illustrate the application of our results. Lastly, we study the case of the minimal repair policy in detail.
Genetic predisposition to obesity can stimulate an increase in adiposity throughout adulthood. However, the interaction between genetic factors and dietary habits may modify the genetic association with obesity. Thus, this study aimed to investigate the dietary patterns that influence the genetic risk of obesity in a Korean population using a large cohort study and genome-wide association study.
Design:
Prospective cohort study.
Setting:
The genetic risk score (GRS) was calculated based on six identified SNP of the OTOL1, NMBR, DNAJB9, ASCC1, NT5C2 and FTO genes associated with obesity, as ascertained by BMI. Dietary patterns were determined using food intake data from an FFQ and factor analysis.
Participants:
This study included data from 8458 adults aged 40–69 years from the Ansan and Ansung cohorts of the Korean Genome and Epidemiology Study.
Results:
The refined carbohydrate dietary pattern showed a significant inverse association with obesity in the highest GRS group with a non-significant interactive association (OR: 0·801; 95 % CI: 0·662, 0·969; P for trend = 0·0251, P for interaction = 0·571). However, participants with the highest refined carbohydrate dietary pattern score and highest GRS had an increased prevalence of obesity (OR: 1·288; 95 % CI: 1·068, 1·554; P for trend = 0·0251) compared with the prevalence of those with the lowest dietary pattern score and GRS.
Conclusions:
Reducing refined carbohydrate consumption may be helpful for Korean adults with a greater genetic susceptibility to obesity.
This article proposes and studies two Huber-type estimation approaches, namely, the Huber instrumental variable (IV) estimation and the Huber generalized method of moments (GMM) estimation, for a spatial autoregressive model. We establish the consistency, asymptotic distributions, finite sample breakdown points, and influence functions of these estimators. Simulation studies show that compared to the corresponding traditional estimators (the two-stage least squares estimator, the best IV estimator, and the GMM estimator), our estimators are more robust when the unknown disturbances are long-tailed, and our estimators only lose a little efficiency when the disturbances are short-tailed. Moreover, the Huber GMM estimator also outperforms several robust estimators in the literature. Finally, we apply our estimation method to investigate the impact of the urban heat island effect on housing prices. A package is published on GitHub for practitioners to use in their empirical studies.
This paper uses China’s 2016 Pollutant Discharge Permits System (PDPS) to evaluate its impact on innovation in the food processing industry. We begin by exploring the entry and exit decisions of food processing firms. The findings suggest that stricter environmental enforcement following the PDPS leads to decreased local firm entry but increased neighboring firm entry, indicating that new firms tend to locate in neighboring regions with less stringent regulations. Building upon this pattern, we argue that the PDPS’s positive impact on firm innovation is primarily driven by increased industry agglomeration – a dynamic directly stimulated by heterogeneous regulatory pressures.
The clock drawing test is widely used in clinical neurological and neuropsychological assessment. We hypothesized that younger adults would have greater problems with clock drawing than older adults, perhaps due to decreasing analog clock use.
Methods:
Cross-sectional study analyzing clock drawing performance and cognitive function across four generations (Gen Z, Millennials, Gen X, Baby Boomers). Participants included 92 adults divided into two generations (63 younger [18–42 years old] and 29 older [43–77 years old]) assessed between October 2022 and December 2024. Participants were screened to exclude conditions affecting cognition. The primary outcome was performance errors in clock drawing (e.g., writing “11:10” instead of drawing an analog clock, or placing hands incorrectly), assessed using standardized criteria. Cognitive function was assessed using eight computerized tests (CogState) measuring processing speed, attention, executive function, visuospatial memory, and verbal memory. Confirmatory factor analysis (CFA) validated three cognitive domain composites: Speed/Attention, Executive/Spatial, and Verbal Memory.
Results:
Performance errors were significantly more prevalent among younger participants compared with older participants (p = .016; risk ratio, 4.45). The effect size was large (Cohen’s h = .63). The generation effect was stronger (OR = 28.66, p = .003) after controlling for CFA-validated cognitive domain composites. This provides strong evidence that generational differences are independent of cognitive abilities.
Conclusions:
Younger adults demonstrate significantly higher rates of clock drawing errors compared with older adults, independent of cognitive performance. These findings suggest a need for generation-specific or age adjusted norms in clock drawing test interpretation.
The environmental effects of state ownership are still controversial. The ‘reverse privatization’ phenomenon of injecting state capital into non-state-owned enterprises offers a novel perspective to study the environmental impact of state ownership. Using data on Chinese listed companies from 2011 to 2021, this study empirically analyses the impact of state capital injections (SCAI) on firms’ green innovation. Our results reveal that SCAI has a positive effect on the quantity and quality of green innovation, reflecting the net outcome of opposing forces. SCAI promotes green innovation by enhancing firms’ innovative capabilities and willingness, increasing environmental regulatory pressure and reducing managerial myopia, though it may hinder such innovation by exacerbating agency problems and policy burdens. Moreover, SCAI’s positive effects on green innovation quantity and quality are more pronounced for firms with relatively high state capital control, in heavily polluting industries and in less marketized regions.
To identify key factors associated with varying levels of Medicare’s Chronic Care Management (CCM) programme implementation in rural primary care practices in the United States.
Background:
Despite demonstrated benefits for both patients and providers, CCM implementation remains low nationwide. While previous studies have examined payment-related challenges, limited research exists on other implementation factors such as leadership engagement, organizational culture, and provider training, particularly in rural settings.
Methods:
This mixed-methods study examined CCM implementation across six rural primary care practices in Wyoming. Thirteen healthcare professionals participated in semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR). Practice performance data collected over three consecutive months were used to categorize sites as high or low implementers based on care coordinator productivity, percentage of care coordinated, and programme sustainability. Interview transcripts were analysed using CFIR constructs to identify factors that distinguished high from low-implementing sites, with each factor rated based on its impact (positive, negative, or neutral) and strength of influence.
Findings:
Three CFIR constructs strongly distinguished between high and low implementation sites: networks and communication, leadership engagement, and reflecting and evaluating. High-implementing sites demonstrated effective team communication, supportive leadership, and regular programme evaluation practices. In contrast, low-performing sites faced poor communication, minimal leadership support, and weak feedback mechanisms. Further research is needed to examine the effectiveness of targeted interventions designed to strengthen these organizational factors in rural primary care settings, particularly focusing on developing scalable strategies that account for resource limitations and geographic isolation.
In a ruling delivered on 1 August 2025, the Court of Justice upheld a General Court judgment annulling the classification as a suspected carcinogen of titanium dioxide in powder form containing at least 1% of particles of a diameter equal to or below 10 μm. Both EU Courts criticise the scientific assessment underlying that classification, but the Court of Justice relies on conceptual distinctions that reveal its reluctance to perform a genuine “manifest error of assessment” review. While these issues are not addressed by the Court of Justice, the case also raises thorny questions regarding the meaning of “intrinsic properties” of a substance.
To compare neurological and functional outcomes after ultra-early microdiscectomy (≤12 h) versus later surgery (12–24 h, 24–48 h, >48 h) in adults with acute lumbar disc herniation presenting with motor weakness and/or cauda equina syndrome.
Methods:
We retrospectively studied 300 consecutive adults undergoing emergency microdiscectomy (2015–2025) at a tertiary center. Patients were grouped by time from presentation to surgery (≤12 h, 12–24 h, 24–48 h, >48 h). Primary outcomes were motor recovery (Medical Research Council scale) and pain improvement; secondary outcomes were complications, length of stay (LOS), recurrent emergency visits and recurrent herniation. Nonparametric tests and logistic regression were used with a prespecified significance level of p < 0.001.
Results:
Ultra-early surgery was associated with more rapid immediate motor gains, most notably in plantarflexion/dorsiflexion, and shorter LOS (≤12 h: 3.8 days; >48 h: 6.2 days). Over the ≤48 h window, long-term motor recovery did not differ among ≤12 h, 12–24 h and 24–48 h groups. Rates of complications, recurrent emergency visits and recurrent herniation did not vary by timing.
Conclusion:
In acute presentations with neurological deficits, microdiscectomy performed within 48 h remains the key threshold for favorable outcomes. Ultra-early surgery (≤12 h) appears to accelerate early neurological recovery and reduce LOS in selected acute cases, without evidence of superior long-term motor outcomes versus other ≤48 h windows. Prospective, symptom-stratified studies are warranted.
The lower Cambrian Cranbrook Burgess Shale-type Lagerstätte (Series 2, Stage 4) occurs within the Eager Formation of southeastern British Columbia, Canada. This deposit consists of claystone intercalated with normally graded mudstone, which has medium silt to very fine-grained sand and disarticulated skeletal debris near the bed bases, recording mostly accumulation from turbidity currents. Well known for its olenelloid trilobites in particular, the site also contains rare soft-bodied fossils, including Tuzoia carapaces and Anomalocaris claws, and low-diversity and low-density suites of ichnofossils. A 2015 systematic field investigation of a 2.65 m interval recovered 12 ichnotaxa and three types of trace fossils left in open nomenclature. The most abundant are Helminthoidichnites tenuis Fitch, 1850, Palaeophycus tubularis Hall, 1847, Diplocraterion isp., and finger-like structures (FLS). These trace fossils form two ichnocoenoses recurring through the studied interval: (1) the Helminthoidichnites tenuis ichnocoenosis, consisting of small trails and shallow burrows, and (2) the Diplocraterion isp. ichnocoenosis, consisting of paucispecific suites of U-shaped burrows, commonly associated with FLS. The FLS contain a diverse range of disarticulated or broken trilobite sclerites and grains coarser than the host sediment and are interpreted as passively infilled burrows, suggesting significant sediment bypass and trapping of transported grains. Overall, the Cranbrook ichnocoenoses do not display a well-defined tiering structure. The trace fossils overall record the activities of a surficial epifauna and a shallow-tier infauna that colonized the sea bottoms during short windows between episodic flows and inhabited dysoxic (Helminthodichnites tenuis ichnocoenosis) to relatively well-oxygenated (Diplocraterion isp. ichnocoenosis) outer shelf environments.
Social media often follow a visual logic found to increase engagement, as images are more likely to attract attention, presenting information on a holistic-associative basis. For a political entity like the EU, social media are a promising route to overcome the remoteness to its citizens, identified as one of the crucial challenges to its public legitimacy. Against this broader background, our study analyses the influence of 10 years of EU visual social media communication on user engagement as an indicator of successfully creating visibility in a crucial communication space. For this purpose, we conducted an image-type analysis, combining quantitative and qualitative features of visual analysis: First, a subsample of posts was inductively analysed to identify recurring image types and subsequently used to implement a manual quantitative visual content analysis. Building on the results, we drew on a machine learning approach, allowing us to analyse over 40,000 posts, including more than 20,000 pictures. Our results emphasise the crucial influence of social media affordances in explaining user engagement with EU visual social media communication. Implications are discussed with reference to the ongoing discussion about the EU’s democratic deficit.
In the 1970s, activists in the Youth International Party transformed new technologies and techniques in the American telephone system into tools for advancing the political aims of the New Left. The Yippies adopted new practices of telephone “hacking” or “phone phreaking” and developed these practices to manipulate, defraud, and protest the AT&T Bell System. Appeals to and protests of “the system” invoked the image of a broader American state. The practice of phone phreaking bridged the technical exploitation of AT&T with critiques of monopoly capitalism, state surveillance, postwar conformity, and American empire. By the late 1970s, as the New Left faded in prominence and the Bell System was itself broken up, the vernacular of system changed. Within an emerging “computer underground” of phreaks, hackers, and users connected through electronic bulletin board systems, the Yippie vernacular of system was reinterpreted as a critique of the state in the language of ascendant conservative and libertarian politics.
It is crucial to properly evaluate the traits that directly impact agricultural productivity. Some of these traits, such as soil erosion or crop diseases, are quantified with scoring systems. The resulting data are strictly ordinal and often have an underlying percentage scale. Deciding which model to use for this type of data is not straightforward. Ordinal scores do not meet the assumptions required for analysis of variance. Although multinomial ordinal models, particularly the threshold model, can be applied, they do not account for the underlying percentage scale of the data. To address this limitation, a hurdle model tailored for interval-censored percentage data is proposed. It is a two-part model that models the data according to their nature: In its first part, it models presence or absence of a disease (incidence), and in the second part it models severity or abundance. Individually modelling presence and absence in the first part allows to account for zero inflation. The second part implements theory from the threshold model and the Johnson SB system of distributions that involves a transformation of the percentage scale to a normal distribution. The model result also reflects the two components. They individually describe the degree of disease infestation, and the degree of disease spread. This improves interpretability and enables concrete, insightful conclusions. To illustrate the model, mildew scorings from an on-farm trial in grapevines were used. The model was found highly suitable for this dataset and superior to the threshold model.
Compressible wall-bounded turbulent flows exhibit complex mean profiles because of the pronounced compressibility effects and heat transfer. We propose a hybrid transformation framework to collapse compressible mean velocity and temperature profiles onto incompressible forms through scaling each layer by its effective transformation, with the underlying mapping functions discovered via a physics-informed symbolic regression (PISR) method. The hybrid velocity transformation incorporates an intrinsic compressibility correction for the buffer layer and a PISR-derived mapping function for the logarithmic layer. For temperature, we introduce a hybrid transformation that integrates the Mach-invariant-type transformation in the viscous sublayer and a novel PISR-derived scaling in the logarithmic layer. The performance of these transformations is evaluated across compressible turbulent boundary layers with free-stream Mach numbers ranging from 0.5 to 8 and wall-to-recovery-temperature ratios ranging from 0.25 to 1. The hybrid velocity transformation outperforms Griffin–Fu–Moin transformation for the transformed mean velocity profiles, with the mean integrated percent error across the dataset decreasing from 1.67 % to 0.96 %. The hybrid temperature transformation performs better than the Mach-invariant-type and Trettel–Larsson-type transformations for mean temperature profiles. Moreover, the inverse hybrid velocity and temperature transformations can effectively predict the compressible mean velocity and temperature profiles with only wall conditions.
Although stably stratified shear flows, where the base velocity shear is quasi-continuously forced externally, arise in many geophysically and environmentally relevant circumstances, the emergent dynamics of their ensuing statistically steady stratified turbulence is still an open question. We address this phenomenon in a series of three-dimensional direct numerical simulations using spectral element methods. We consider a forced, stably stratified shear flow with an initial bulk Reynolds number $\textit{Re}_{0} = 50$, an initial bulk Richardson number $\textit{Ri}_{0} = 1/80$ (also corresponding to the initial minimum gradient Richardson number $\textit{Ri}_{{g}}$) and a fluid of Prandtl number ${\textit{Pr}} = 1$ in horizontally extended domains. Although the initial configuration is unstable to a primary Kelvin–Helmholtz instability, the ensuing turbulence is sustained by continuously relaxing the resulting flow back towards the initial profiles of streamwise velocity and buoyancy. We study statistical as well as structural aspects of the final statistically steady flows, including the flux coefficient $\varGamma _{\chi }$ and dynamically emergent length scales $\varLambda$ associated with the large-scale dynamics, respectively. Despite the ongoing stirring and mixing, we find that the shear layer half-depth converges to a finite value of $d \approx 8$ (i.e. $\varLambda _{z} \approx 16$) once the horizontal extent of the domain $L_{{h}} \gtrsim 96$. While this implies a final ${{Re}} \approx 400$ and ${Ri} \approx 0.1$, we hypothesise that such forced flows ‘tune’ themselves eventually to a state of a gradient Richardson number $\textit{Ri}_{{g}} \lesssim 0.2$, consistently with several previous studies. Moreover, provided sufficiently extended domains, we observe the emergence of large-scale flow structures with spanwise $\varLambda _{\!y} \approx 50$ and streamwise $\varLambda _{x} \lesssim 115$. Clearly, these observations demonstrate the marked anisotropy of characteristic emergent length scales, even for such ‘weakly stratified’ forced shear flows. We conjecture that the actual emergent streamwise structures are a vestigial ‘imprint’ in the sheared turbulent flow of the primary linear instability of the converged deepened turbulent shear layer.
Relationships among teachers are known to influence their teaching-related perceptions. We study whether and how teachers’ advising relationships (networks) are related to their perceptions of satisfaction, students, and influence over educational policies, recorded as their responses to a questionnaire (item responses). We propose a novel joint model of network and item responses (JNIRM) with correlated latent variables to understand these co-varying ties. This methodology allows the analyst to test and interpret the dependence between a network and item responses. Using the JNIRM, we discover that teachers’ advising relationships contribute to their perceptions of satisfaction and students more often than their perceptions of influence over educational policies. In addition, we observe that the complementarity principle applies in certain schools, where teachers tend to seek advice from those who are different from them. The JNIRM has the potential to improve the cost efficiency of network studies by integrating network and item response information during model estimation.